CHAPTER © 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6 Office Visit: Patient Intake

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes When you finish this chapter, you will be able to: 6.1Identify the four stages of patient flow. 6.2Discuss the main sections of the patient chart. 6.3Describe the procedures for recording a patient’s past medical, family, and social history. 6.4Explain how allergies and intolerances are entered in the patient chart. 6.5Describe the procedure used to enter patient medications. 6.6Explain how the chief complaint is recorded in a progress note. 6-2

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Learning Outcomes (Continued) When you finish this chapter, you will be able to: 6.7Explain how a patient’s vital signs are recorded in the patient chart. 6.8Explain the uses of an intra-office messaging system in an EHR. 6.9Describe how letters are created in an EHR. 6-3

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. Key Terms family history (FH) history of present illness (HPI) past, family, and social history (PFSH) past medical history (PMH) patient flow progress notes review of systems (ROS) social history (SH) 6-4

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.1 Patient Flow in the Physician Office 6-5 Patient flow—progression of patients from the time they enter the office for a visit until they exit the system by leaving the office after a visit A typical patient flow consists of four stages: –Check-in –Patient intake –Examination –Checkout

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.1 Patient Flow in the Physician Office (Continued) 6-6 Progress note—note documenting the care delivered to a patient, and the medical facts and clinical thinking relevant to diagnosis and treatment Past, family, and social history (PFSH)— commonly used abbreviation for past medical, family, and social history Past medical history (PMH)—patient’s history of medical problems, including chronic conditions, surgeries, and hospitalizations

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.1 Patient Flow in the Physician Office (Continued) 6-7 Family history (FH)—detailed record of medical events among members of the patient’s family, including the ages, living status, and diseases of siblings, children, parents, and grandparents Social history (SH)—information about the patient’s tobacco use, alcohol and drug use, sexual history, relationship status, and other significant social facts that may contribute to the care of the patient

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.1 Patient Flow in the Physician Office (Continued) 6-8 History of present illness (HPI)—description of the course of the present illness, including how and when the problem began, up to the present time Review of systems (ROS)—inventory of body systems in which the patient reports signs or symptoms he or she is currently having or has had in the past

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.2 The Patient Chart in Medisoft Clinical Patient Records 6-9 The main sections of the patient chart window in MCPR include: –Patient identifying information (at the top and the bottom of the window) –Chart folders (similar to paper folders) –Notes area (used to enter notes about the patient)

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.3 Medical History 6-10 The medical history section of the patient chart includes three folders: –Past Medical History –Social History –Family History Each history section of the chart consists of a single note. To enter a patient’s history, open a patient’s chart, and click the appropriate history folder. –If none exists, it can be created by clicking Yes when a message appears.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.3 Medical History (Continued) 6-11 To enter a patient’s history: –Open a patient’s chart, and click the appropriate history folder. –If no chart exists, it can be created by clicking Yes when a message appears asking about creating a new note. –Click in the body of the note and begin typing. –Click the OK button to save the note.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.4 Allergies 6-12 To record and store patient allergies: –Click the Rx/Medications folder; the Rx/Medications dialog box is displayed. –To add a patient’s allergies and intolerances, click the Allergy button; the Allergy dialog box is displayed. –Complete the fields and click the OK button to save the allergy information. –The information will be added to the list at the top of the Rx/Medications dialog box.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.5 Medications 6-13 There are three tabs in the Rx/Medications dialog box: –Current –Ineffective –Historical To enter patient medications: –Use the Current tab of the Rx/Medications dialog box. –Click the New button to record current medications; the Prescription dialog box will appear. –Complete the fields in the Prescription dialog box.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.6 The Chief Complaint 6-14 In most practices, the chief complaint is entered as the title of the progress note for the patient’s visit. To create a progress note (chief complaint): –A patient chart must first be open. –Click the Note button on the toolbar, or, to open an existing note, click the Progress Notes folder. –Enter the title and date as needed, and click the OK button. MCPR allows for the use of shared notes, which are signed by each contributor.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.7 Vital Signs 6-15 Patients’ vital sign measurements are entered in the Vital Signs folder in the patient chart. To record a patient’s vital signs: –Click the New button; the Vital Signs dialog box is displayed. –Select the keypad feature via a drop-down list; then enter numeric entries by using this keypad or by typing directly in the field. –Click the OK button to save the entries.

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.8 Messages 6-16 Staff members can send intra-office messages using MCPR. Messages can be used to: –Communicate with staff members –Set up a reminder system or to-do list –Send attachments –Link the reader to the relevant portion of a patient’s chart –Send messages ranked by priority

© 2012 The McGraw-Hill Companies, Inc. All rights reserved. 6.9 Letters 6-17 Letters are sent to patients, other providers, employers, insurance companies, and others. To create a letter in MCPR: –Click the Letter button on the toolbar, or select Letters on the Task menu; the Insert Template dialog box will be displayed. –Select a template from the list of letter templates and click the Insert button; the template will be inserted into the body of the letter. –Write the letter and click OK to save when done, or use the Print button.